DEPARTMENT(S): Grievance & Appeals
REPORTS TO: Director, GARS
FLSA STATUS: Exempt
SALARY GRADE: P - $117,000 - $165,000
JOB SUMMARY:
This position is responsible for the development and management of the Grievance and Appeals Resolution Services (GARS) Department for Member Appeals and Grievances Services. The incumbent will ensure full compliance with all state and federal laws, regulations, rules and contract requirements as set forth by the Department Health Care Services (DHCS), Department of Managed Health Care (DMHC) and, the Centers for Medicare and Medicaid Services (CMS) and any other governmental entities with regulatory authority. Participates in all regulatory audits pertaining to grievance and appeals. Stays current with all new regulatory guidelines that impact grievance and appeals for all CalOptima programs. Staff development and the ability to build and foster a team environment are essential.
POSITION RESPONSIBILITIES:
- Maintains oversight of member grievances, appeals, State Fair Hearings and Administrative Law Judge (ALJ) hearings in adherence with regulatory requirements. Ensures quality assurance within clinic operations are met or exceeded through effective performance monitoring and utilization of nursing practice standards. Ensures that clinical and medical protocols and rules for the grievance and appeals process are followed.
- Reviews and analyzes Appeals, Grievances and State Fair Hearing data along with audit results to improve root causes of member dissatisfaction and implement action plans and workflows for improvement to achieve member/provider satisfaction and operational effectiveness/efficiencies when assigned to Member Appeals and Grievances Services, sets direction and goals for nursing and clinical managers and supervisors to ensure clinic operations integrate with other GARS program services.
- Manages employees directly and through subordinate manager(s); responsible for selection, training, developing, reviewing, setting department and individual performance goals to enhance professional development.
- Designs and implement resource and capacity management strategy to maximize efficiencies in grievance and appeals handling.
- Proactively communicates with and advise key leadership regarding process improvements, project status, risks, issues, and priorities with leadership.
- Lead, coordinate, and monitor policy and procedural changes and maintain the process for revision and implementation that supports plan regulatory compliance.
- Perform audits to monitor compliance with policies and regulatory requirements, as well as ensuring process/operational efficiencies.
- Co-Lead Grievance and Appeals quarterly committee meeting and attend all internal committees within the CalOptima Organization to report activities and trends.
- Oversee staff assignments to ensure effective allocation of resources to ensure state and federal regulations are meet and establish production standards for the department.
- Responsible for job descriptions, interview and hire new staff members, orientation, training programs for Grievance and Appeals staff, both new and existing, and annual evaluations for assigned staff.
- Maintains current knowledge of regulatory requirements pertinent to Grievance and Appeals (DHCS, CMS, DMHC, NCQA).
- Participate in all state and federal regulatory audits as the business lead as it relates to grievance and appeals.
- Performs special projects and other duties as assigned.
KNOWLEDGE & ABILITIES:
- Communicate effectively with health professionals and administrators, both verbally and in writing.
- Work in an extremely fast-paced environment with multiple competing priorities and matrix reporting relationships.
- Make decisions in a timely manner and clearly communicate to all organizational levels at both a vertical and horizontal manner.
- Present statistical and technical Grievance and Appeals data in a clear and understandable manner utilizing appropriate visual aids.
- Motivate and lead departmental staff and various participants at all levels in the organization.
- Establish and maintain effective interpersonal relationships across functional and enterprise boundaries and build relationships with other departments, programs, agencies, and the public to achieve business goals.
- Develop a team of support resources that may not functionally report to the position to achieve the task at hand.
- Identify pertinent policy issues; develop strategies, solutions and recommendations.
- Analyze health care data to assess the policy implications for CalOptima’s programs.
EXPERIENCE & EDUCATION:
- Bachelor’s degree or equivalent combination of education and experience required.
- 4 years healthcare grievance & appeals experience in a managed care organization required.
- 4 years of management/leadership experience in a healthcare company required.
- Current, unrestricted RN License to practice in the State of California is required.
- Strong interpersonal skills including coaching staff and handling conflict resolution is required.
PREFERRED QUALIFICATIONS:
- HMO, Medi-Cal/Medicaid, Medicare and insurance experience or relevant government client or public service experience preferred.
KNOWLEDGE OF:
- Knowledge of State and Federal regulatory statutes, including Medicare Parts C and D and Medicaid.
- Strong analytical, problem solving and interpersonal skills.
- Self-starter with outstanding critical thinking and relationship building skills.
- Proficient with Microsoft Office (Word, Excel, and PowerPoint).
- Excellent verbal and written communication skills.
- Principles and methods of planning, directing, and maintaining compliance with regulatory standards.
- Principles and practices of health care service delivery, managed care, health care systems, and medical administration and NCQA accreditation standards.
- Medi-Cal, Medicare, Cal MediConnect program services, regulations, and benefits, including state and federal standards and regulations for member and provider rights and responsibilities.
- Appropriate techniques to serve diverse social and ethnic groups and to communicate effectively with them.
CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
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Required Skills
Required Experience